Elsevier

The Lancet

Volume 377, Issue 9765, 12–18 February 2011, Pages 587-598
The Lancet

Series
Human resources for health in India

https://doi.org/10.1016/S0140-6736(10)61888-0Get rights and content

Summary

India has a severe shortage of human resources for health. It has a shortage of qualified health workers and the workforce is concentrated in urban areas. Bringing qualified health workers to rural, remote, and underserved areas is very challenging. Many Indians, especially those living in rural areas, receive care from unqualified providers. The migration of qualified allopathic doctors and nurses is substantial and further strains the system. Nurses do not have much authority or say within the health system, and the resources to train them are still inadequate. Little attention is paid during medical education to the medical and public health needs of the population, and the rapid privatisation of medical and nursing education has implications for its quality and governance. Such issues are a result of underinvestment in and poor governance of the health sector—two issues that the government urgently needs to address. A comprehensive national policy for human resources is needed to achieve universal health care in India. The public sector will need to redesign appropriate packages of monetary and non-monetary incentives to encourage qualified health workers to work in rural and remote areas. Such a policy might also encourage task-shifting and mainstreaming doctors and practitioners who practice traditional Indian medicine (ayurveda, yoga and naturopathy, unani, and siddha) and homoeopathy to work in these areas while adopting other innovative ways of augmenting human resources for health. At the same time, additional investments will be needed to improve the relevance, quantity, and quality of nursing, medical, and public health education in the country.

Introduction

Since India gained independence, universal and affordable health care has been central to the planning of the country's health system;1 substantial government effort and resources have been devoted to the creation of a wide network of public sector health facilities (ie, primary health centres and subcentres, community health centres, district hospitals, and tertiary hospitals), at which qualified health workers can provide low-cost services. However, attempts to establish such a network have been unsuccessful because substantial socioeconomic and geographical inequities exist in access to health care and health outcomes in India. Many Indians, especially those living in rural areas, do not receive health care from qualified providers.2, 3

Although the public sector is the main provider of preventive care services, 80% of outpatient visits and 60% of hospital admissions are in the private sector.4 Consequently, 71% of health spending is out of pocket, and, every year, such expenditure forces 4% of the population into poverty.4, 5 On the whole, the absence of adequately trained health-care providers in public and private sectors is a major cause for concern. Urgent reforms are needed, particularly in human resources, to achieve universal and affordable health care in India.

In this report we review the existing state of human resources for health in India and provide direction for future reform efforts.

Section snippets

Background

In 1947, when India gained independence, it had few adequately trained health workers. and only 1·6 doctors per 10 000 population.6 Most physicians (70%) worked in the private sectors in urban areas.1 The two classes of allopathic physicians were doctors who undertook a 5·5-year medical degree and licentiate medical practitioners who underwent a 3–4-year course. Nearly two-thirds of qualified medical practitioners were licentiates who worked mainly in rural areas.7, 8 Additionally, many

State of human resources in health

India's health workforce is made up of a range of health workers who offer health-care services in different specialties of medicine (panel 2). The workforce includes many informal medical practitioners, generally called registered medical practitioners, such as traditional birth attendants (known locally as dais), herbalists, snake-bite curers, and bone setters. For most of the population, especially the poor, registered medical practitioners are often the first point of contact for treatment.

Health workforce size

Reliable and systematic data for health workers in India are difficult to obtain (panel 3). Estimates for 2005 (based on the 2001 census) suggest that India had almost 2·2 million health workers, including about 677 000 allopathic doctors and 200 000 practitioners of ayurveda, yoga and naturopathy, unani, siddha, and homoeopathy.21 India has roughly 20 health workers per 10 000 population (figure 1). The total health-care workforce consists of allopathic doctors (31%), nurses and midwives

Distribution

Health workers are unevenly distributed across the country (figure 2). Generally, the north-central states, which are some of the poorest in terms of economy and health, have low numbers of health workers. The numbers of health workers per 10 000 population in India range from 23·2 in Chandigarh to 2·5 in Meghalaya. The numbers of allopathic doctors per 10 000 people in states such as Goa (41·6) and Kerala (38·4) are up to three times higher than in states such as Orissa (19·7) and Chhattisgarh

Shortages

The public health system has a shortage of medical and paramedical personnel. Government estimates (based on vacancies in sanctioned posts) indicate that 18% of primary health centres are without a doctor, about 38% are without a laboratory technician, and 16% are without a pharmacist.35 Specialist allopathic doctors are in very short supply in the public sector; 52% of sanctioned posts for specialists at community health centres are vacant. Of these vacant posts, 55% are for surgeons, 48% are

International migration

Many doctors, nurses, and technicians emigrate from India, which contributes to the country's shortage of health workers. Indian doctors constitute the largest number of foreign trained physicians in the USA (4·9% of physicians) and the UK (10·9% of physicians), the second largest in Australia (4·0% of physicians), and third largest in Canada (2·1% of physicians).40, 41, 42 The Planning Commission cites WHO16 to show that about 100 000 Indian doctors work in the USA and the UK.43

Migration seems

Medical education

Since independence, access to medical education has increased substantially in India. At the time of independence, India had 19 medical schools, from which 1200 doctors graduated every year.51 Nowadays, according to the Medical Council of India, India has roughly 270 medical schools, from which 28 158 doctors graduate every year.52 Private medical institutions have helped this rapid increase in medical education (figure 4).53 In 1990, 33% of 135 medical schools were privately operated;

Nursing education

In India education for nurses has also increased rapidly. In 2006, there were 271 teaching institutions for auxiliary nurse midwives, 1312 offering the general nurse midwifery degree, 580 offering bachelors degree in nursing, and 77 offering masters degrees in nursing.65 Private nursing institutions have added to the increase in nursing education. Of the nursing colleges offering courses in general nurse midwifery, 88% were private sector institutions.65 Corporate sector hospitals have also

Provider quality

Insufficient investments in medical and nursing education have largely caused India's crisis in human health resources.43 Poor quality of care in the public sector, particularly at peripheral health facilities, is often cited as the reason for people seeking private medical care. State incentives for the development of the health tourism industry has led to many health personnel moving from the public to the private sector, which has contributed to the lower standards in the public sector.69

Recent initiatives

The Indian Government is aware of the additional requirements and shortages in the availability of health workers for the future. The National Rural Health Mission, for instance, recommends a vastly strengthened infrastructure, with substantial increases in personnel at every tier of the public health system.80

According to the National Rural Health Mission, a district of 1·8 million people should have about 400 sub-centres, 50 primary health centres, nine community health centres, and a

Way forward

India urgently needs to develop a national human resource policy. Such a policy should also examine the creation and establishment of cadres of trained health professionals (medical and non-medical) who can provide leadership (technical and administrative) and direction to the health sector in the states and nationally. Such cadres could correct the imbalance in competencies and improve channels of communication between technical and administrative personnel in addition to providing necessary

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